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In recent years there has been increasing attention to the need to help smokers who cannot quit, so that they can find other means to minimise their risk for tobacco induced diseases. This is a matter of adopting the principle of ”Harm reduction” in tobacco control just as this is established practice in alcohol and drug control. In order to put these matters in context, we need an overview of goals and objectives in the field of tobacco control.

The overall goal for tobacco control can be formulated as: ” Reducing tobacco-related morbitity and mortality as far as possible”. This goal includes intermediate objectives for practical measures to help specific target groups such as: Never tobacco users, and Current tobacco users.

The objective of measures to help never tobacco users should be: PREVENTING ONSET OF TOBACCO USE. The strength of such measures is: In individuals for whom these measures have been successful, tobacco induced diseases will not occur. But there are weaknesses: - Measures to prevent onset of tobacco use have limited success rate. - Even when they are successful, there is virtually no reduction of disease in the nearest 30-40 years, because, in that period, virtually all cases of tobacco induced diseases will occur among those who already smoke. This is further illustrated by data published in a report from the World Bank .

The curves in this graph show the estimated cumulative tobacco deaths 1950 to 2050 by different intervention policies, The black curve represents a ”no intervention” scenario. The red curve represents a scenario where onset of smoking in young people has been cut to half from the year 2000 to 2020 - a quite optimistic scenario. But the result in terms of reduction of deaths is very modest. However, in a still longer time perspective, prevention of onset will yield substantial health gains. So, primary prevention policies are important - but not enough. The World Bank has also estimated the outcome of a scenario where adult smoking is cut to half from the year 2000 to 2020.

As illustrated by the blue curve, quitting smoking makes a substantial difference, and the health gain appears quite soon. Therefore……..

The #1 objective of measures to help current tobacco users should be: QUITTING ALL TOBACCO/NICOTINE USE The strength of such measures is that they can make disease risks decrease substantially, eventually approaching never-user levels. But there are weaknesses: - Treatments in clinical settings reach a limited fraction of smokers and have limited success rate. - Quit attempts made outside clinical settings (the majority of all quit attempts) get no or inadequate support. In summary; Cessation policies are important - but not enough. Some reasons behind the weaknesses of cessation policies can be illustrated by ”real life” data regarding quit attempts.

Some smokers do not make any quit attempt at all. In Sweden this group is quite small, less than 10% of all ever daily smokers, but in many other countries the percentage is substantially higher. Even more important is the outcome of actual quit attempts. Among those who have made one or more quit attempts, there are large proportions who do still smoke. These proportions differ substantially according to level of nicotine dependence.

The proportion of those who do still smoke is increasing with increasing level of nicotine dependence. For those with very high level of dependence it may be virtually impossible to quit nicotine use. Consequently, we need a separate objective for measures to help these people minimise their health risks by other means.

This objective should be: Switching to a nicotine product that is markedly less harmful than cigarettes. The strength of this strategy is, that it offers a realistic alternative even for highly nicotine dependent people, and also, that disease risks can decrease almost as much as when quitting. And there are weaknesses: - Continued exposure to nicotine - Maintenance of nicotine dependence - Limited availability of appropriate products This raises the question: ”What is markedly less harmful”?

(See text on slide and here below) Snus is the kind of oral smokeless tobacco manufactured and widely used in Sweden. Ariva and Stonewall are American oral smokeless tobacco products.

In this chart each whole bar represents the relative risk of death for males with different tobacco use The green sector of each bar represents never smokers’ death risk, taken as a reference. The red sector in the bars for snus users and cigarette smokers represents the excess risk, above that of never smokers. For users of snus, the Swedish kind of smokeless tobacco, the death risk is much closer to that of never smokers than to that of cigarette smokers.

In order to study the health effects of switching to snus and of quitting all tobacco use an Australian study has estimated the reduction of life expectancy for different tobacco use trajectories. Compared to ”Never tobacco users” (as a reference losing 0 years of life expectancy), continuing smokers lose 4 – 5 years. Those who either switch to snus or quit totally, lose MUCH less than continuing smokers, and the loss for ”snus only” users is even less than for switchers or quitters.

There has been some concern that, even if switching to snus is beneficial for individuals’ health, there might be unintended negative effects on public health, if many switchers would otherwise have quit totally. The Australian researchers have, however, found that the small difference between switchers and quitters make such an outcome extremely unlikely (first point on the slide). Negative effects related to onset of snus use appear similarly unlikely (second point on the slide)

While the previous slides have demonstrated that switching to snus or quitting totally can yield important health benefits, there are widespread fears that both snus and medicinal nicotine products (chewing gums and patches) may be almost as harmful as smoking. The data on this picture show the perceptions of men and women in the Swedish population.

This picture presents corresponding data for subgroups with different background in terms of education and socioeconomic status. As far as nicotine gum and patch is concerned perceptions are clearly more consistent with the scientific evidence in higher education groups, while the corresponding trend is weaker as far as snus in concerned.

Some non-smoking nicotine delivery products do not only have a role as a long term alternative to cigarettes but also as pharmaceutical aids in tobacco cessation. This was discussed by Professor John Hughes at a symposium in Stockholm in April 2008.

In a list of Medications Under Study, Professor Hughes included three categories of nicotine products: Faster oral NRT Snus True nicotine inhalers

In a Swedish study respondents were asked about details of their latest quit attempt. One question dealt with use or no use of some cessation aid and, if so, which one. This diagram shows, for each one of the three main aid user categories, the outcome of the latest quit attempt. Red sector of each bar represents failure, i.e. continuing daily smoking, light green sector represents quitting daily smoking while continuing to smoke occasionally, and dark green represents quitting smoking completely. Both in men and women, use of snus as cessation aid, gave more successful outcome of the quit attempt than any of the two types of NRT. The pattern remains the same in subgroups with different age and level of education.

P reviously, governmental policies have largely neglected the need to help smokers who cannot quit. But, in May 2008 it was recognised by the British Department of Health.) In the background document for a ”Consultation on the future of tobacco control”, the Brtish Department of Health identifies four main areas. One is: ”Helping those who cannot quit”: considering…… (text on slide) ……..… quit altogether.” In early August 2008 The Royal College of Physicians of London responded to the consultation by publishing a report summarizing updated scientific evidence in the field.

Already in the subtitle the report highlights the harm reduction component of the suggested ”Radical strategies” for ”Ending tobacco smoking in Britain”. The following slides will show some excerpts from the report.

2.
OVERALL GOAL for tobacco control: Reducing tobacco-related morbidity and mortality as far as possible <ul><li>INTERMEDIATE OBJECTIVES for practical measures in tobacco control </li></ul><ul><li>These will be s pecific for measures to help different target groups, for example :  Never tobacco users  Current tobacco users </li></ul>

3.
Objective of measures to help never-tobacco-users: Preventing onset of tobacco use <ul><li>Strength:  In individuals for whom these measures have been successful, tobacco induced diseases will not occur </li></ul><ul><li>Weaknesses: </li></ul><ul><li> Measures to prevent onset of tobacco use have limited success rate  Even when successful: Virtually no reduction of disease in nearest 30–40 years </li></ul>

6.
#1 objective of measures to help current tobacco users: Quitting all tobacco/nicotine use <ul><li>Strength:  Disease risks decreasing substantially, eventually approaching never-user levels </li></ul><ul><li>Weaknesses:  Treatments in clinical settings reach a limited fraction of smokers and have limited success rate  Quit attempts made outside clinical settings (the majority of all) get no or inadequate support </li></ul>

7.
Occurrence of quit attempts in Sweden (% of all ever daily smokers) Men Women  Not made any quit attempt 9% 8% <ul><li> Made one or more quit attempts - but do still smoke 36% 47% - and have quit completely 55% 45% Source: ITS/FSI surveys of the Swedish population </li></ul>

9.
#2 objective of measures to help current tobacco users Switching to a nicotine product that is markedly less harmful <ul><li>Strengths: </li></ul><ul><li> Realistic alternative even for highly nicotine dependent people  Disease risks potentially decreasing almost as much as when quitting </li></ul><ul><li>Weaknesses:  Continued exposure to nicotine  Maintenence of nicotine dependence  Limited availability of appropriate products </li></ul>

12.
Reduction of life expectancy: Tobacco users, age 40, in comparison with ”Never tobacco users” Estimated number of years lost Men Women Current smokers who continue to smoke 5.04 4.09 Current smokers who quit all tobacco use 0.53 0.34 Current smokers who switch to snus 0.77 0.52 Current snus users who never smoked 0.28 0.19 Source: Gartner CE et al. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet 2007; 369: 2010-2014

13.
Gartner CE et al. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet 2007; 369: 2010-2014. Excerpts from the Summary: <ul><li>For net harm to occur, 14–25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus rather than continuing to smoke. </li></ul><ul><li>Likewise, 14–25 people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking. </li></ul>

19.
Main area #4 Helping those who cannot quit: considering the potential of a harm reduction approach in tobacco control to help people whose addiction to nicotine makes it extremely difficult to quit altogether.

21.
Excerpt from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008. <ul><li>What is harm reduction, and how would it work for smoking? </li></ul><ul><li> People smoke because they are addicted to nicotine, but nicotine itself is not especially hazardous; it is the other constituents of tobacco smoke that cause most of the harm. </li></ul><ul><li> Harm reduction is therefore feasible in tobacco smoking by providing smokers with nicotine from a source that does not involve inhaling tobacco smoke. </li></ul><ul><li> Use of smoke-free nicotine would benefit smokers directly by reducing the personal harm caused by nicotine addiction. </li></ul>

22.
Excerpt from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008. <ul><li>What is the safest way to provide nicotine without smoke? </li></ul><ul><li> The safest form of nicotine is medicinal or ‘pure’ nicotine, such as that contained in nicotine replacement therapy (NRT) products including skin patches and chewing gum. </li></ul><ul><li> Medicinal nicotine is by far the safest alternative to smoking, other than quitting nicotine use altogether. </li></ul><ul><li> However, although helpful, few smokers find NRT to be a satisfying alternative to smoking. </li></ul><ul><li> This is partly because NRT products deliver lower doses of nicotine, and deliver them more slowly, than cigarettes. </li></ul>

23.
Excerpt from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008. <ul><li>What are the alternatives to medicinal nicotine? </li></ul><ul><li> Nicotine can also be obtained without smoke from a range of tobacco products, usually referred to as ‘smokeless’ tobacco. </li></ul><ul><li> All smokeless tobacco products are therefore more hazardous than medicinal nicotine, and in some cases especially so, but all are also substantially less hazardous than smoking. </li></ul><ul><li> In Sweden, the availability and use by men of an oral tobacco product called snus, one of the less hazardous smokeless tobacco products, is widely recognised to have contributed to the low prevalence of smoking in Swedish men and consequent low rates of lung cancer. </li></ul><ul><li> However, the Swedish data provide proof of concept that substitution of smokeless for smoked tobacco can be effective as a harm reduction strategy. </li></ul>

24.
Summary and conclusions (1) <ul><li>Primary prevention policies are important </li></ul><ul><li>- but not enough </li></ul><ul><li>Smoking cessation policies are important </li></ul><ul><li>- but not enough </li></ul>

25.
Summary and conclusions (2) <ul><li>Smokers who are unable or unwilling to be without nicotine should be offered less harmful alternatives to cigarettes, such as medicinal nicotine or low risk types of smokeless tobacco. </li></ul>

26.
Summary and conclusions (3) <ul><li>Alternative nicotine delivery products should be strictly regulated in order to safeguard that only products that are markedly less harmful than cigarettes are available. </li></ul>